Rule 4741-1-21 | Recordkeeping.
(A) A veterinarian performing a physical examination, diagnosis, treatment or surgery on an animal or group of animals shall prepare a written record or computer record concerning the animals containing, at a minimum, the following information:
(1) Name, address, and telephone number of owner;
(2) Identity of the animal, herd, or flock;
(3) Except for herds or flocks, the age, sex, color, and breed;
(4) Dates of examination, treatment and surgery;
(5) Brief history of the condition of each animal, litter, herd, or flock;
(6) Examination findings;
(7) Laboratory and radiographic tests performed and reports;
(8) Differential diagnosis;
(9) Procedures performed/treatment given and results;
(10) Drugs (and their dosages and routes of administration) administered, dispensed, or prescribed;
(11) Surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agent used, the route of administration and the dosage; and
(12) Anesthesia monitoring performed during surgical procedures.
(B) Individual records must be maintained on each patient, except that records on livestock or litters of animals may be maintained on a per-client basis.
(C) Medical records and radiographs are the physical property of the hospital or the proprietor of the practice that prepared them. Records, including radiographs, must be mintained for a minimum of three years after the last visit.
(D) Medical records shall be released upon request from a treating veterinarian with a legitimate interest, and shall be returned to the originating practice within a reasonable time if requested. Copies of records must be made available upon request from the owner of an animal at a reasonable cost to the owner and within a reasonable time. A veterinarian may not withhold the release of veterinary medical records for nonpayment of a professional fee.
(E) All regulated substances shall be recorded as required by federal and/or state regulations
Last updated April 14, 2022 at 8:55 AM
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